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A Series of Blastomycosis Cases Associated With Septic Shock FREE TO VIEW

Ravi Agarwala, MD; Syed Ahmed, MD
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Wake Forest School of Medicine, Winston-Salem, NC

Chest. 2013;144(4_MeetingAbstracts):382A. doi:10.1378/chest.1702186
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SESSION TITLE: ICU Infections Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 30, 2013 at 01:30 PM - 02:30 PM

PURPOSE: Blastomyces dermatitidis is a fungus encountered by the Mississippi and Ohio Rivers, the Great Lakes and in Northwestern Ontario. It is recognized as a cause of pulmonary infection in these areas, including cases associated ARDS and poor outcomes. Cases presenting with septic shock have not been described per se. We present a recent cohort with associated septic shock.

METHODS: Thunder Bay serves as a tertiary referral center for Northwestern Ontario. We performed a single-center retrospective case review from June 2004 to November 2010. Medical Records identified patients with a diagnosis of blastomycosis. The investigators reviewed patient records and data was collected on patients meeting standard criteria for septic shock. All patients had culture-proven blastomycosis. Given the small number of cases, qualitative comparisons between survivors and non-survivors were made.

RESULTS: We identified 44 patients with a diagnosis of blastomycosis. 16 had ARDS: 7 had ARDS alone and 9 also had septic shock at presentation. There were no patients with shock without ARDS, and all has shock at presentation. All had positive respiratory cultures for Blastomyces dermatitidis. One patient has a secondary cerebral focus. All patients received amphotericin-based therapy. The mean age was 47.4 years and patients were symptomatic for an average of 8.6 days. The mean APACHE II score was 18.2. 6 patients died and 3 survived to hospital discharge. Survivors had a shorter duration of illness prior to ICU admission (5 vs 10 days) and lower APACHE II scores at presentation (14 vs 20) and at 5 days (21 vs 34). The use of other therapies was similar in both groups.

CONCLUSIONS: Septic shock appears to be an extension of severe pulmonary infection complicated by ARDS. This is consistent with the postulate that the lung is the primary site of blastomycosis infection. Mortality is similar to that of older blastomycosis-ARDS series in spite of contemporary ICU care. In our series, the principal differences appear to be a shorter duration of symptoms and lower presenting APACHE scores for survivors. Early recognition and treatment appear crucial.

CLINICAL IMPLICATIONS: In endemic areas, blastomycosis should be considered in the differential diagnosis of severe pneumonia with ARDS/septic shock and empiric antifungal coverage may be warranted.

DISCLOSURE: The following authors have nothing to disclose: Ravi Agarwala, Syed Ahmed

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